Comment for the Federal Trade Commission Workshop: Health Care Competition, Project No P13-1207. March 17, 2014 I am an Advanced Practice Registered Nurse (APRN) with National Board Certification as a Child-Adolescent & Adult Community Mental Health Clinical Nurse Specialist (since 1990), a PhD in Philosophy & Nursing Research (1997), and more recently National Board Certification as Family Psychiatric / Mental Health Nurse Practioner (2012). I worked as a rural RN from 1962 - 1990. The laws, rules and regulations in Missouri are extremely restrictive for one of my profession. In Missouri, I must have a collaborative psychiatrist partner (CP) who meets these regulations: 1) My CP and I have worked in the same physical office/hospital for 30 days before I can work at a separate site. 2) Elsewhere must be no further than 50 road miles for my rural location, or 30 miles in urban settings. 3) I cannot work if my CP is gone, or I must have a back-up CP to cover the first CP absence. 4) My CP must sit at my site every two weeks for an estimated two hours to review 20% of my physical records and sign the review. Which means an hour to drive almost 50 miles to the county, making a total of 4 hours every other week for a physician who is already over-loaded. From August 10, 2009, to December 1, 2012, I searched within 50 road miles around my rural site including Kansas City for a CP. A total of 27 physicians declined to partner with me for my rural setting. I was ready to give up! In December I found a Psychiatrist in Columbia who would be my CP, If I drove to Boonville (one hour to central Missouri from my home and 20 minutes for the physician). I am now commuting to stay in a rural setting as I use my skills. I do not have a back-up CP for his days out of office. My "hands are tied" by current laws for working the county of my residence. I have attended legislative sessions the last three years in Missouri to help loby for APRN autonomy for practice. I have been greatly dismayed by the powerful physician lobyists who speak of the necessity to "supervise" APRNs. Our Missouri law states APRNs "may" collaborate with physicians and nothing about being "supervised". As Dr. Olivia L. Young wrote so well in her comment, APRNs are each skilled and competent for autonomy in our specialty. AND, RNs have been checking on physicians since the beginning of our profession to protect patients/consumers from physician errors. My experience observing the physician lobyists at Jefferson City "feels" like the physicians are trying to restrict APRNs services in a state and culture where there are too few providers and an overwhelming need by our citizens to receive mental health and many other APRN's specialty care. For three years the physician lobyists have blocked APRN efforts for autonomy, not willing to consider that 17 other states have legal autonomy for APRNs. No other state has the four restrictions named above. Missouri is the most restrictive in the Nation. I will continue to go with many APRN leaders to Missouri's Capitol Hill to loby for the freedom to provide quality APRN care to citizens in Missouri, and for me it will be the rural citizens where I live. I look forward to the day when I can work without driving an hour to be near enough to my "Collaborative Partner" to be legal. I will follow your website for the information provided from your Health Care Competition Workshop March 20-21. I appreciate this opportunity to offer my opinion. Thank You. Sincerely, Frances D. Atkins, PhD, BC C-A & A CMH CNS, BC FPMHNP